Forms
A form is necessary to enroll in the plan or to make changes to your current elected plan. Below you will find a printable version of each Medical and Prescription enrollment form. An enrollment form is needed for the retiree and the spouse, if both are enrolling or make a plan change.
- 2022 EB Change Form
- 2022 EB Prescription Drug Opt Down Form
- 2022 EB Medicare Plan Election Form
- 2022 Limited RX Enrollment Form
- 2022 Value RX Enrollment Form
- EB Mail Order Form
- Application for Enrollment into Medicare Part B
- Social Security- Employment Information Form (for EB employees retiring post age 65)
- Premium Adjustment form for High Income
- Medicare Savings Program CT Brochure
- Medicare Savings Program CT - New Application
- Medicare Savings Program CT - Renewal Application
- Medicare Savings Program Q&A
- MetLife Dental Form
